Abdominal radiograph requesting in the setting of acute abdominal pain: temporal trends and appropriateness of requesting

Utilization of abdominal radiography in the emergency department: Appropriateness, interpretation, radiation protection and costs

INTRODUCTION

The use of abdominal radiography (AXR) apparently continues to be widespread despite its limited indications, the potential radiation and unnecessary costs associated. In addition, the interpretation and its report seem variable and not always performed by a radiologist. Our objective is to analyze the use, adequacy and usefulness of AXR in the emergency of a tertiary referral hospital.

MATERIAL AND METHODS

We retrospectively reviewed all the AXR performed in January 2020 in the emergency of our centre, as well as the patient's demographics and medical records, technical quality of the radiographs, indications according to the SERAM (Spanish Society of Radiology) Appropriateness Guidelines, presence of a formal radiology report, and impact on the clinical management of the patient. Of all non-appropriated AXR we calculated the radiation received by the patients and its extra costs.

RESULTS

In January 2020, 429 AXR (9.1% of all radiographies) were performed in the emergency of our centre. The most frequent indication was abdominal pain (40%, n = 176), followed by low back pain (21.4%, n = 92). 12.4% of AXR requested did not include any clinical information. Most of the AXR (79.6%) had sufficient technical quality. 61.3% (n = 263) of the AXR performed were not indicated, assuming an average unjustified radiation dose per patient of 0.50 ± 0.33 mSv, and a total additional cost of 6575;. Only 6% of the inadequate AXRs led to a change in the clinical management of the patient, compared to 29% of the adequate AXR (p < 0.001). Only 3% of the AXR had a formal radiology report.

CONCLUSIONS

AXR is still common in the emergency setting, although most of them might be inadequate according to the SERAM Appropriateness Guidelines. Its use should be optimized to avoid unnecessary radiation and costs. Radiologists must have a more active participation in the management of AXR.

Current abdominal X-rays practice in accident and emergency

INTRODUCTION

Previous literature reviews revealed that abdominal X-rays (AXR) performed for the accident and emergency department (A&E), had low sensitivity, high further imaging and non-alignment rate to the Royal College of Radiologists (RCR) guidelines. A study was performed to investigate the current practice with the aim of making recommendations to improve practice, which can reduce patients' radiation exposures, while can re-routing resources to other priorities.

METHODS

A study was performed in one of the UK's largest A&Es, in accordance with the RCR guidelines. All the AXR requests from A&E, regardless of the patient's age, within a 28-day period, were retrospectively assessed. Non-A&E patients and abandoned examinations due to uncooperative patients were excluded. The total number of AXR requests received by the A&E imaging department was 169, with 28/169 falling into the exclusion criteria.

RESULTS

Of the 141 included requests, five unjustified requests were correctly rejected. The remaining 136 requests were accepted and performed, though only 115/136 (84.6%) of these were justified. The most common justified and unjustified indications were obstruction and renal stones, respectively. Only 4% of reported AXR had pathological abnormalities, while 45/136 patients had further imaging.

CONCLUSIONS

The small proportion of significant findings echoed previous studies, suggesting an AXR overuse. Over 80% of non-compliant requests were performed, and awareness of the justification guidelines can be increased by clinical governance, posters, or an algorithm previously presented. The 32.4% further imaging rate recorded in this study, as opposed to the 73.7% reported in previous literature, merits attention.

IMPLICATIONS TO PRACTICE

Stopping the overuse of AXR can minimise the radiation dose received and relieve the mounting pressure in imaging and reporting, which can serve other patients who would benefit from the services otherwise.

The utility of the abdominal series in the emergency setting: a retrospective review

PURPOSE

The abdominal series (AXR) remains a frequently ordered test in the emergency department (ED), despite existing literature questioning its utility. The aim of this study was to characterize the use of the AXR in the ED by quantifying how often it is ordered and the frequency of subsequent imaging. Additionally, a time estimate in ED associated with the AXR was quantified. We hypothesized that there would be a low clinical utility of the AXR, and long associated time period spent in the ED.

METHODS

A retrospective audit of AXRs performed in the ED from January to December 2019 was performed. The local picture archiving and communication system (PACS) and electronic medical record were used to collect the variables.

RESULTS

Of 701 AXRs, 438 (62.4%) were reported normal, and 263 (37.6%) were abnormal. A Chi Squared test showed that the two variables (abdominal series result and follow up imaging completion) were significantly related, with p < 0.001. However, the effect size was small (Nagelkerke R square = 0.022). The average time spent in the ED for these patients was 7.27 h, and the average time between the AXR being ordered and interpreted was 1.31 h.

CONCLUSION

The majority of AXRs were reported as normal. Our results showed that AXR had a statistically significant, but low clinically significant predictive ability on subsequent imaging ordering. This supports our hypothesis that the AXR is of low clinical utility with respect to the rate of ordering follow up imaging. The AXR also translated to a quantifiable time interval during the patient's stay in ED. Minimizing overuse of the AXR may result in a decrease in patient duration in the ED.

Measuring appropriateness of diagnostic imaging: a scoping review

In radiology, the justification of diagnostic imaging is a key performance indicator. To date, specific recommendations on the measurement of appropriateness in diagnostic imaging are missing. To map the study literature concerning the definition, measures, methods and data used for analyses of appropriateness in research of diagnostic imaging. We conducted a scoping review in Medline, EMBASE, Scopus and the Cochrane Central Register of Controlled Trials. Two independent reviewers undertook screening and data extraction. After screening 6021 records, we included 50 studies. National guidelines (n = 22/50) or American College of Radiology Appropriateness Criteria (n = 23/50) were used to define and rate appropriateness. 22/50 studies did not provide methodological details about the appropriateness assessment. The included studies varied concerning modality, amount of reviewed examinations (88-13,941) and body regions. Computed tomography (27 studies, 27,168 examinations) was the most frequently analyzed modality, followed by magnetic resonance imaging (17 studies, 6559 examinations) and radiography (10 studies, 7095 examinations). Heterogeneous appropriateness rates throughout single studies (0-100%), modalities, and body regions (17-95%) were found. Research on pediatric and outpatient imaging was sparse. Multicentric, methodologically robust and indication-oriented studies would strengthen appropriateness research in diagnostic imaging and help to develop reliable key performance indicators.

Knowledge translation: Radiographers compared to other healthcare professionals

OBJECTIVES

This narrative review examines the current status of evidence-based practice and knowledge translation in diagnostic radiography. It explores knowledge translation efforts in the allied health professions aimed at systematically implementing evidence-based practice and suggests ways that these may be applied within diagnostic radiography.

KEY FINDINGS

Knowledge translation in diagnostic radiography is in its infancy with numerous examples of key findings of rigorous studies not implemented in practice. Utilising frameworks, models and theories to systematically translate knowledge into evidence-based practice has been shown to be effective in other allied health professions. Whilst few studies in diagnostic radiography report utilising these systematic approaches to implementing evidence-based practice, those that do, show promising results. Attitudes towards evidence-based practice within diagnostic radiography are becoming more positive and it is important to use this positive shift in attitudes to create real evidence-based change in the profession.

CONCLUSION

The potential benefits of systematically translating knowledge into evidence-based practice in diagnostic radiography are wide reaching with positive implications for our patients, the profession and wider community. Leaders at all levels of radiography must work towards implementing evidence-based practice in their daily work.

IMPLICATIONS FOR PRACTICE

Systematic approaches to knowledge translation should be adopted and reported in diagnostic radiography in order to more effectively translate knowledge into evidence-based practice.

Overuse of plain abdominal radiography in emergency departments: a retrospective cohort study

BACKGROUND

Plain abdominal radiography (PAR) is routinely performed in emergency departments (EDs). This study aimed to (1) identify the indications for PAR in EDs and compare them against international guidelines, (2) uncover predictors of non-compliance with guidelines, and (3) describe the use of additional radiological examinations in EDs.

METHODS

Retrospective cohort study in the EDs of two hospitals in Geneva, Switzerland, including all adult patients who underwent PAR in the EDs. Indications were considered "appropriate" if complying with guidelines. Predictors of non-compliance were identified by univariate and multivariate analyses.

RESULTS

Over 1 year, PAR was performed in 1997 patients (2.2% of all admissions). Their mean age was 59.7 years, with 53.1% of female patients. The most common indications were constipation (30.8%), suspected ileus (28.9%), and abdominal pain (15.3%). According to the French and American guidelines, only 11.8% of the PARs were indicated, while 46.2% of them complied with the Australian and British guidelines. On multivariate analysis, admission to the private hospital ED (odds ratio [OR] 3.88, 95% CI 1.78-8.45), female gender (OR 1.95, 95% CI 1.46-2.59), and an age >  65 years (OR 2.41, 95%CI 1.74-3.32) were associated with a higher risk of inappropriate PAR. Additional radiological examinations were performed in 73.7% of patients.

CONCLUSIONS

Most indications for PAR did not comply with guidelines and elderly women appeared particularly at risk of being exposed to inappropriate examination. PAR did not prevent the need for additional examinations. Local guidelines should be developed, and initiatives should be implemented to reduce unnecessary PARs.

TRIAL REGISTRATION

ClinicalTrials.gov , identifier NCT02980081 .

Appropriateness of adult plain abdominal radiograph requesting in a regional Emergency Department

INTRODUCTION

Although commonly ordered, abdominal x-rays are thought to be overused and unhelpful in many emergency department patients. Our objectives were to evaluate the appropriateness of plain abdominal X-ray (AXR) requests in adult patients presenting to a Victorian regional emergency department (ED).

METHODS

A retrospective chart review was performed of all adult patients with a plain AXR requested by ED medical staff members in a regional healthcare centre in Victoria, Australia in 2016. Patient demographics, ED disposition and any further imaging results were extracted from the medical record. Indications for X-ray and clinician seniority were determined from the radiology request slips signed by the treating emergency doctor. Appropriateness of imaging was determined by comparing the indication for abdominal radiograph to local evidence-based guidelines.

RESULTS

One hundred and nine episodes of plain AXR requests met the inclusion criteria. Of these, 40 were considered inappropriate according to clinical guidelines. Overall, 36% (39/109) had normal or non-specific findings and 42% (46/109) demonstrated faecal loading, while 22% (24/109) identified pathology. Thirty-three patients had further imaging, mostly with computed tomography (CT). Junior staff members were responsible for most of the AXR requests.

CONCLUSION

In our regional hospital ED, over one third of AXRs requested for adult patients were inappropriate according to clinical guidelines. AXRs have a low diagnostic yield and frequently do not reduce the need for further imaging. The use of a clinical practice guideline and education of junior medical staff may increase the appropriate use of plain AXRs in the regional ED setting.

The evaluation of compliance with iRefer guidelines for abdominal imaging and the impact of the normal abdominal radiograph on the clinical confidence and decision making of emergency clinicians

INTRODUCTION

Attendance of adult patients to the Emergency Department (ED) with acute abdominal pain is a frequent event. Abdominal X-ray imaging (AXR) is commonly the first line of investigation but previous studies have suggested that the AXR has no place in assessing acute abdominal pain because of its low diagnostic yield and limited contribution to direct clinical decision making. However, no evaluation of the impact of a negative AXR on the clinical confidence and decision making of emergency clinicians has been undertaken. This study aims to fill this gap.

METHOD

A self-designed paper questionnaire was distributed to medical clinicians on ED placement at a single NHS trust in the South of England. The survey sought to explore the impact of the negative AXR on clinical confidence and decision making and compliance with iRefer guidelines for referring to alternative imaging modalities (ultrasound and computed tomography) should the option to refer for AXR be restricted.

RESULTS

A total of 28 (n = 28/41; 68.3%) completed questionnaires were returned. Most clinicians (n = 18/28; 64.3%) indicated that negative AXR had little impact on their clinical decision making although a small majority (n = 10/18; 55.6%) acknowledged it provided greater clinical confidence in their decision making. Variable compliance with iRefer guidelines for referral to ultrasound and computed tomography was noted.

CONCLUSION

Whilst the negative AXR did not impact on the clinical decision making of most ED clinicians, it did increase clinical confidence. Consequently, the AXR should remain a referral option in the workup for adult patients presenting with acute abdominal pain to the emergency department.

Abdominal radiographs in the emergency department: current status and controversies

This editorial is discussing about the indiscriminate use of abdominal radiographs in the emergency department in general, with focus on value of the erect abdominal radiograph for the diagnosis of mechanical bowel obstruction and paralytic ileus.

Erect chest radiography in the setting of the acute abdomen: essential tool or an unnecessary waste of resources?

INTRODUCTION

It has been suggested that changes to the training schemes of junior doctors and the increased pressure on emergency departments to manage their patients within a limited time might increase the number of unnecessary investigations performed on emergency admission patients. This, in turn, may lead to an increased number of investigations with normal results. In this study we try to analyse the role of the chest X-ray (CXR) as a diagnostic tool in patients presenting with acute abdominal pain.

PATIENTS AND METHODS

A retrospective study was performed of the request forms and results of all chest radiography performed on patients admitted on the emergency surgical intake with acute abdominal pain through utilisation of the prospectively maintained electronic radiology database. The indications were compared to the guidelines published by the Royal College of Radiologists (RCR) which have been adopted as the standard of care.

RESULTS

A total of 334 chest X-rays were identified of which only 23 (7%) had new findings. Four (1%) patients had free gas under the diaphragm. Of the CXRs, 258 (77%) were reported normal whilst 53 (16%) had old changes which were described in their hospital records and previous radiographs. Of the CXRs with new findings, only 20 were clinically significant and, of these, four (1%) were surgically significant.

CONCLUSIONS

The majority of CXRs performed on emergency surgical admissions with abdominal pain are unnecessary. By obtaining a clear history, performing a thorough clinical examination and following the RCR guidelines most of the CXRs could be avoided. This would lead to less radiation exposure, reduce delays to diagnosis, and provide significant financial savings.

Single-centre experience of radiation exposure in acute surgical patients: assessment of therapeutic impact and future recommendations

BACKGROUND

Radiological investigations have become a key adjunct in patient management and consequently radiation exposure to patients is increasing. The study objectives were to examine the use of radiological investigations in the management of acute surgical patients and to assess whether a guideline-based radiation exposure risk/benefit analysis can aid in the choice of radiological investigation used.

METHODS

A prospective observational study was completed over a 12-week period from April to July 2008 for all acute surgical admissions. Data recorded included demographics, clinical presentation, differential diagnosis, investigations, surgical interventions, and final clinical outcome. The use of radiological investigative modalities as an adjunct to clinical assessment was then evaluated against The Royal College of Radiologists (RCR) guidelines.

RESULTS

A total of 380 acute surgical admissions (M = 174, F = 185, children = 21) were assessed during the study period. Seven hundred thirty-four radiological investigations were performed with a mean of 1.93 investigations per patient. Based on the RCR guidelines, 680 (92.6%) radiological investigations were warranted and included 142 CT scans (19.3%), 129 chest X-rays (17.6%), and 85 abdominal X-rays (11.6%). Clinically, radiological imaging complemented surgical management in 326 patients (85.8%) and the management plan remained unchanged for the remaining 54 patients (14.2%). This accounted for an average radiation dose of 4.18 millisievert (mSv) per patient or 626 days of background radiation exposure. CT imaging was responsible for the majority of the radiation exposure, with a total of 1310 mSv (82.6%) of the total radiation exposure being attributed to CT imaging in 20.8% of acute admissions. Subgroup analysis demonstrated that 92.8% of the CT scans performed were appropriate.

CONCLUSION

Radiation exposure was generally low for the majority of acute surgical admissions. However, it is recommended that CT imaging requests be evaluated carefully, particularly for patients with clinically confirmed pathologies and in younger women.

Measurement of process as quality control in the management of acute surgical emergencies

BACKGROUND

Quality of care measured by adverse events cannot address errors of process that have no adverse outcomes. The aim of this study was to determine whether process could be used to assess quality of care and whether process analysis could be used to assess interventions designed to improve quality.

METHODS

A single-centre prospective cohort study was performed over 12 weeks in an acute surgical admission unit. Data were collected prospectively for the first 24 h of admission on three aspects of process: documentation, general management and presentation-specific criteria. After a period of observation, the impact of three interventions (active observation, increasing awareness and issuing a job description) on the mean number of process errors per patient (process score) was compared.

RESULTS

The analysis was based on 566 patients admitted with general surgical pathology. Awareness of being observed failed to improve the process score. Interventions that increased awareness of process reduced the overall process score from 4.79 to 2.38 errors per person (P < 0.001). The mean overall process score in patients with an adverse event was twice that of patients who did not have an adverse event (5.74 (95 per cent confidence interval 4.03 to 7.45) versus 3.43 (3.19 to 3.66)).

CONCLUSION

Process can be measured objectively and used as a measure of quality of care. Interventions to increase awareness reduced process error rates and adverse events.